977 Joe Rd f , .-fin .�. •` - -. .- �. 1'`- - r � •�,1. /ti _
DAVIE COUNTY, HEALTH- DEPARTMENT.
p brt , IMPROVEMENTS .PERMIT AND;CERTIFICATE OF -COMPLETION }
p
*NOTE:, 'lssued in Compliance with-G.S.of SNorth.'CaroIina-Chapter 13b Article.13c
Sewage,Treatment,'and Disposal Rules l'(10 NCAC' 10k.1934-1968) �f t Permit Number •.b
Name :.Date 4.�40
location
Subdivision.NameLot No. Sec. or Block Na.
Lot Size - C HouseMobile Home _ Business Speculation
No. Bedrooms ,No. Baths - No. in Family
Garbage Disposal*. ' YES ❑ NO 2—
Specificationsr for System:
Auto Dish Washer -YES EP, NO,❑ y
Auto Wash Machine YES NO '❑ ,, -
. /�/ ,�- SII i •1,,,...e�C,/.�'�j/f"/ �`f•fir ., .
Type Water Supply
Ij
*This.permit.Void if sewage system .described 6 w is of installed within 36 months from date of issue._ ' •
•- � - III • '
• rl,
ImproVemeuts,permit by
*Contact a representative of the Davie County HealthlDepartment%,fpr final yinspecti61n,of this system between'8 30;
9:30 A.M. or 1:00;.1:30 P.M. on day o. c mpletion. elephone Number: 704-634-5985.
..
Final Installation .Diagram: " stem.Installed by
• .. iii �?-� • ._ . .. ;'
Certificate of Completion Date
"The signing of this certificate shall'indicate that.jh6 system described 'above has been installed'in' compliance*•with •
the standards set forth in'the above regulation, bu#;shall in NO'way.be taken.as a guarantee that the system will function :;
satisfactorily for any given period of time.. y.
i
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
�
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
P PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Solis S PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS PS
14P U U U
External S S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S- S S
PS PS PS
U U U U
8) Other (Specify) S S S
PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by ':14lZ TitleDate
SITE DIAGRAM
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT "t• 23
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone
1. Permit Requested By�,)-F Cor✓y�`>"Ze/� Business Phone _ 917T q�S
2. Address 3 130,1 9L72 M-0r-kSy;//e- , A6 e-, A7oa3K
3. Property Owner if Different than Above MV;p h? shu l e i-
Address AU-3 lhocAsv;//e, /V, C. O�sr
4. Permit To: a) Install `Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House M�ome Business
IndustryOther
b) Number of people '3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions '� 4 ;X 3 D
Bed Rooms 3 Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes �- urinals garbage disposal
lavatory 9, showers a washing machine /
dishwasher I sinks 3
8. a) Type water supply: Public PrivateCommunity
b) Has the water supply system been approved? Yes t--'�No
9. a) Property Dimensions—
b)
imensions b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? y�
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner SicKature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: —A I
j2 � -
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DCHD(6-82)